Breast, bottle, cup

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Breast, bottle, cupWho is confused?!

• Acute Paediatric Feeding EBP and Discussion Group
• EBP extravaganza 2008

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Breast, bottle, cup Who is confused?!

• Recent changes to infant feeding practices
• Promotion of exclusive breast feeding for first
  six months of life / WHO
• Baby friendly hospital initiative and breast
  feeding guidelines
• Alternate methods of supplemental feeding

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Breast, bottle, cup Who is confused?!

• Policy Statement NSW Health
• Breastfeeding is the biological norm and most
  beneficial method for feeding infants with
  immediate and long -term health outcomes for
  mother and infant and is to be actively promoted,
  protected and supported by the NSW Health system
  (p5)
• Breastfeeding in NSW Promotion, Protection and
  Support Policy Directive, 2006

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Breast, bottle, cup Who is confused?!

• Maternity Services Ten Steps to Successful
  Breastfeeding
• Every facility providing maternity services and
  care for newborn infants should
• 1. Have a written breastfeeding policy that is
  routinely communicated to all health care staff.
• 2. Train all health care staff in skills
  necessary to implement this policy.
• 3. Inform all pregnant women about the benefits
  and management of breastfeeding.

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Breast, bottle, cup Who is confused?!

• 4. Help mothers initiate breastfeeding within
  half an hour of birth.
• 5. Show mothers how to breastfeed, and how to
  maintain lactation even if they should be
  separated from their infants.
• 6. Give newborn infants no food or drink other
  than breast milk, unless medically indicated.
• 7. Practise rooming-in - that is, allow mothers
  and infants to remain together - 24 hours a day.

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Breast, bottle, cup Who is confused?!

• 8. Encourage breastfeeding on demand.
• 9. Give no artificial teats or pacifiers (also
  called dummies or soothers) to breastfeeding
  infants.
• 10. Foster the establishment of breastfeeding
  support groups and refer mothers to them on
  discharge from the hospital or clinic.

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Breast, bottle, cup Who is confused?!

• Impact on special care nurseries and premature
  babies
• Other evidence for use of dummies for suck
  training in premature infants (Ref Cochrane
  Database 2005, Pinelli, J Symington)
• Extra support required for premature babies to
  establish any successful suck feeding
  specialist caseload

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Breast, bottle, cup Who is confused?!

• EBP group felt
• Recommendations in some breast feeding documents
  cite nipple confusion as a barrier to
  establishing breast feeding ? no evidence for
  nipple confusion
• suck feeding of any kind (bottle / finger
  feeding with supply line) more normal oral motor
  process for newborns than cup feeding
• Cup feeding is not a biological norm for
  newborn infants

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Breast, bottle, cup Who is confused?!

• Formulating our clinical question
• How can we support BF in special care nurseries
  and still provide appropriate care for babies
  with special needs?
• Initially considered looking at Does nipple
  confusion exist?
• Nipple confusion is cited many nursing articles,
  but not specifically researched ? dead-end
  search!

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Breast, bottle, cup Who is confused?!

• Preliminary look at cup feeding vs bottle feeding
  ? Cochrane database 2007
• Flint A, New K, Davies MW. Cup feeding versus
  other forms of supplemental enteral feeding for
  newborn infants unable to fully breastfeed.
• Do initial feeding experiences and patterns
  effect establishment of breast feeding, or breast
  feeding duration?

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Breast, bottle, cup Who is confused?!

• Our clinical Question
• In newborns, is there a difference in introducing
  bottle vs cup feeding in establishing and
  maintaining breast feeding?

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Breast, bottle, cup Who is confused?!

• 13 potential articles found
• 5 articles answered both portions of the question
  (establishing and maintaining BF)
• 4 of the 5 studies reviewed were specific to
  preterm infants
• Articles reviewed were all level II and III
  evidence
• See references for full list of articles

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Breast, bottle, cup Who is confused?!

• Results
• Overall there was no statistically significant
  difference between bottle and cup feeding in
  establishing and maintaining breast feeding.
• One study indicated that BF rates were higher for
  cup fed infants at discharge, but hospital stay
  was longer. There was no significant difference
  in BF duration

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Breast, bottle, cup Who is confused?!

• One study indicated that babies delivered by
  caesarean had better BF duration when cup fed (??
  Why)
• One study indicated that cup fed babies MAY have
  better BF duration, but the study was too small
  to elicit significant results

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Breast, bottle, cup Who is confused?!

• Other comments
• Only one study followed babies until 6mths
• One study was a pilot only, and may elicit better
  results if a full project were pursued
• There was poor compliance from parents and
  nursing staff in one larger study, which reduced
  the power of the results

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Breast, bottle, cup Who is confused?!

• Where does that leave us Still confused?

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Breast, bottle, cup Who is confused?!

• Cochrane review on bottle vs cup feeding ? no
  significant difference
• EBP review on cup vs bottle for establishing AND
  maintaining BF ? no significant difference

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Breast, bottle, cup Who is confused?!

• If there is no significant difference between
  them ? does it matter which method is used?

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Breast, bottle, cup Who is confused?!

• Clinical application
• NICU and special care nurseries can function
  outside of BFHI guidelines because they have a
  specialist caseload
• SPs working in NICU / SCBU environments can
  negotiate with individual teams re feeding
  methods and still promote breast feeding use of
  EBM

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Breast, bottle, cup Who is confused?!

• Combined evidence from Cochrane review and EBP
  results can support use of bottle feeding (with
  expressed breast milk - EBM) for pre term infants
• Bottle feeding can be used as an interim step for
  babies who will BF in the longer term

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Breast, bottle, cup Who is confused?!

• Goal / spirit of the breast feeding guidelines is
  to promote breast milk as best nutrition for
  babies in the first 6 months of life. Does method
  of delivery matter?
• SPs aim to facilitate appropriate suck feeding
  for newborns with feeding difficulties, and work
  closely with LCs and nursery staff to achieve
  this, promoting BF whenever possible.

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Breast, bottle, cup Who is confused?!

• Case example
• Term baby with antenatally diagnosed severe
  diaphragmatic hernia
• Surgical repair D19 then ventilated
• CPAP support on and off for 6wks
• Mother very keen to BF

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Breast, bottle, cup Who is confused?!

• First suck feed attempts 8wks after birth (post
  term)
• First attempts were suck feeds of EBM from a
  bottle ? can control flow more easily
  (externally) as well as control volume taken
  (fluid restrictions)

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Breast, bottle, cup Who is confused?!

• First breast feeding attempt 6 days later (9 wks
  after birth) ? joint review by SP and LC
• SUCCESSFUL FIRST BREAST FEED!!!

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Breast, bottle, cup Who is confused?!

• This baby was not confused!

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Breast, bottle, cup Who is confused?!

• References
• Carmel T Collins, Philip Ryan, Caroline A
  Crowther, Andrew J McPhee, Susan Paterson, Janet
  E Hiller. Effect of bottles, cups, and dummies on
  breast feeding in preterm infants a randomised
  controlled trial. BMJ published 18 June 2004
• Gilks, J Watkinson, M. Does cup feeding help
  improve breast feeding rates in pre-term babies?
  Pediatric Research Volume 56(3), September 2004,
  p 509

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Breast, bottle, cup Who is confused?!

• Cynthia R. Howard, Fred M. Howard, Bruce
  Lanphear, Shirley Eberly, Elisabeth A. deBlieck,
  David Oakes and Ruth A. Lawrence. Randomized
  Clinical Trial of Pacifier Use and Bottle-Feeding
  or Cup feeding and Their Effect on Breastfeeding
  Pediatrics 2003111511-518
• Mosley, C Whittle, C and Hicks, C. 2001. A
  pilot study to assess the viability of a
  randomized controlled trial of methods of
  supplementary feeding of breast fed preterm
  babies Midwifery. 17. 150-157

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Breast, bottle, cup Who is confused?!

• Rocha NM, Martinez FE, Jorge SM. Cup or bottle
  for preterm infants effects on oxygen
  saturation, weight gain, and breastfeeding.
  Journal of Human Lactation. 18(2)132-8, 2002
  May.

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THANKS!
Brodie Warren Leader, Acute Paediatric Feeding
EBP and Discussion Group, 2008 brodie.warren_at_hneh
ealth.nsw.gov.au